Inside the April 2009 print
edition of Canadian Healthcare Technology:
to acquire electronic charting and other IT systems
The Victorian Order of Nurses, Canada’s largest home-nursing
organization, has awarded a two-year contract worth more than $10
million to IBM Canada. Under the deal, IBM will completely
computerize and re-engineer the way the agency works – from
front-line nurses and home-care workers to back office planners.
A new form of EHR
The Michener Institute, an educational and training centre in
Toronto, has devised an Electronic Health Record system that’s aimed
at groups, rather than individuals. The solution makes use of
leading-edge technologies, such as giant screens and concurrent
viewing of various diagnostic images.
READ THE STORY
A new book shows how organizations in the United States are
innovating to reduce medical error. In some cases, high-tech systems
are involved, but often, it’s a matter of administrative change.
Northern Ontario uses
innovative technology to create region-wide network
The North Eastern Ontario Network (NEON), consisting of 13 different
healthcare organizations, has linked over 100 different clinical and
business applications using the BizTalk Server integration engine
READ THE STORY ONLINE
How to reduce DI wait
Wait times for diagnostic imaging tests remain high across the
country, with waits for CT and MR exams often averaging two or three
times the provincial targets. We look at how a Nova Scotia hospital
dramatically cut CT wait times.
Are wikis the way?
Wikis just might be the ultimate groupware, enabling any number of
persons to apply their knowledge to a problem. Now, wikis are being
used to solve the challenges faced by healthcare providers.
PLUS news stories, analysis, and features and more.
VON to acquire electronic charting and other IT
By Jerry Zeidenberg
OTTAWA – The Victorian Order of Nurses, Canada’s largest home-nursing
organization, has awarded a two-year contract worth more than $10
million to IBM Canada. Under the deal, IBM will completely computerize
and re-engineer the way the agency works – from front-line nurses and
home-care workers to back office planners.
The project will include the acquisition and deployment of electronic
patient record software, scheduling, financial and human resources
systems, wireless and wired connectivity, and systems for the home
monitoring of clients. The Victorian Order of Nurses, a not-for-profit
organization, operates 52 locations across Canada and has nearly 13,000
staff and volunteers.
“The VON has been around for 112 years, and until now, we’ve done most
things using pens, pencils and paper,” commented Dr. Judith Shamian,
president and CEO. “We couldn’t see ourselves doing another 112 years
this way. This is really about catching up with the 21st century.”
Interestingly, the VON hasn’t to date acquired an electronic medical
record system. That’s something it will do as part of the two-year
project with IBM. Advanced communication systems are also in the offing.
Dr. Shamian noted that the VON currently conducts an enormous amount of
work – about 2 million home visits per year – that could be streamlined
and made more efficient through the use of computerized and networked
Each day, the agency conducts thousands of nursing visits and receives
referral documents that are 10 to 25 pages long – by fax. Those reports
are processed, and then re-faxed. It’s a slow and painstaking process.
“It’s also a poor use of the environment and resources,” commented Dr.
Reports could be processed much more easily, accurately and quickly,
using electronic technologies, she said.
Electronic solutions will also lead to more effective use of the
agency’s human resources. For example, improved communication systems
could alert a visiting nurse that one of her clients had an emergency
and left for the hospital before a scheduled visit – thereby saving the
nurse a good deal of time and trouble.
Dr. Shamian emphasized that the project isn’t simply a matter of
installing various computerized technologies, but instead, it’s a
re-engineering effort. “It’s not simply the purchase of systems,” she
said, “it’s a change in the way we work.
“Technology without the right processes won’t solve the problems,” she
As such, the VON is focusing on improving and streamlining its
operations in three major areas.
First, its back office systems will be overhauled – there will be new
scheduling, financial and HR systems put into place. This will help
personnel at VON office better coordinate care.
Second, front-line care-givers. The way they work – and stay in touch
with their offices – will be re-designed and enhanced.
“We’re assessing the use of smartphones, like BlackBerrys and notebook
computers,” commented Barry Burk, vice president of healthcare solutions
for IBM Canada. “But we’re trying not to let the technology take the
lead. It’s the business process that will drive what they’re using,
whether it’s a phone or a laptop. It will depend on the needs of the
nurse or support worker.”
Third, the VON is seeking to build networked connections to the
organizations that it works with – like health ministries and community
care centres, as well as hospitals, pharmacies and physicians.
“It’s important for us to see what has happened to our client, Mrs.
Smith, when she went to the hospital,” said Dr. Shamian. By the same
token, “it would be useful for the caregivers in hospital to see a
record of the care delivered to Mrs. Smith in her home in the previous
These links and systems will be constructed in each province, as the VON
is a national organization. As such, the new system will need to mesh
with various solutions used by partners in each jurisdiction.
However, Dr. Shamian says it will be important to coordinate what’s
being developed, so that “14 different systems aren’t created in each
province,” and that what’s used in one place is similar to that used in
She said the VON is very much in tune with the program of national
standards that’s being orchestrated by Canada Health Infoway.
On the home care delivery front, the VON is planning to further develop
remote monitoring solutions, which can alleviate shortages of skilled
workers and keep costs in line, while improving the quality of care at
the same time.
Dr. Shamian observed that such monitoring solutions could keep tabs on a
client’s vital signs, alerting caregivers when a person is in distress
or needs attention. “Remote solutions for chronic disease management are
going to become very important,” she said. “We can monitor blood
pressure, glucose and many other vital signs using remote systems.”
By using networked technologies, she added, care-givers and family
members can keep close watch on patients and loved-ones with medical
conditions – often bringing problems to the attention of experts before
things take a turn for the worse.
“We need more of this,” she said. “It will be better for the patients
and better for the system.”
The VON is already testing home monitoring systems, and it is also using
systems that bring expertise to the home using telecommunications. One
example is wound care, in which the visiting nurse can transmit pictures
of a patient’s bedsores and wounds to an expert nurse or doctor at
hospital, hundreds or thousands of miles away.
“Wound management is a very specialized field,” said Dr. Shamian.
“There’s no way you can have an expert in every community. But you can
take pictures with a digital camera and send them to an expert for
advice, whether that person is in Halifax or Vancouver. You can then
plan the next stage of treatment for the patient, right then and there.”
IBM’s Burk said more solutions of this kind are in the planning stages.
“We want to do more analysis at the point-of-care,” he said. Having the
right devices in the hands of nurses, along with the correct systems and
training in place, will allow this kind of expertise to be brought to
the home and the point-of-care.
The VON is also planning development of ‘smart home’ technologies, in
which sensors are placed throughout the homes of patients. This will be
particularly helpful for patients in the early stages of Alzheimer’s,
who need help remembering to perform certain tasks. Sensors can also
alert caregivers if the patient has fallen and can’t get up, or if his
or her weight has dropped to an unhealthy level.
In this and many other areas, the VON will be looking to IBM and its
business partners for solutions. “We’re trying to bring IBM’s brain
power into this,” said Dr. Shamian.
Burk said IBM is contributing a wide-ranging perspective to the project,
particularly in the area of business process re-design. “We’re not just
bringing our experience in healthcare to the project, we’re going to
bring in best practices from other industries, as well,” he said.
The move to re-engineer and computerize should help the VON cope with a
rapid escalation in requests for home-care services.
Indeed, home healthcare is said to be the fastest-growing sector in
healthcare and as the Canadian population ages, demand will increase.
Approximately 900,000 Canadians regularly access home care. Between 1995
and 2002, the number of Canadians receiving home care increased by more
than 60 percent.
Dr. Shamian commented that overhauling the way the VON does business is
a major project, and will take longer than the two years allotted to the
contract with IBM. In particular, she said, “We won’t have a complete
EMR by that time – we’ll have to grow it over time.
Still, she is confident that a great deal will be accomplished in the
next 24 months. “It will get us significantly along the way.”
Michener Institute creates an advanced EHR, ideal
for group work
By Jerry Zeidenberg
TORONTO – As part of its mission to build an innovative curriculum
that’s supported by leading-edge technological solutions, The Michener
Institute for Applied Health Science has devised an ‘EHR On-Demand’.
The new system utilizes emerging touchscreen technology on a 60-inch
large-screen television, a $1,500 computer, and several client-based EHR
platforms – including digital microscopy, a laboratory information
system, a PACS, a radio-therapy information system, and an oncology
treatment planning platform.
Together, the huge touchscreen and advanced software provide a new way
of accessing and analyzing information, one that’s ideal for people
working in groups.
Instead of using a keyboard to call up information on a small monitor,
students and clinicians can use their fingers to launch images and move
them around on the 60-inch screen. It’s a bit dazzling when you first
see it – and almost magical.
Using the technology, several diagnostic images can be displayed at once
on the same monitor – for example, CT slices and PET images, along with
pathology images. Users can zoom in on an image just by pointing. They
can move the images around the screen by ‘pulling’ on them, and they can
merge them by stacking them on top of each other.
And a really futuristic touch – you can move a ‘ring’ over an image of
the patient’s body, and slices will appear in different frames
on-screen, showing CT or pathology images from that very region.
This form of accessing medical information has been demonstrated as
work-in-progress by some healthcare IT vendors, but the application is
now being used at the Michener. At the same time, the educational
institute is developing new applications for the future.
Brad Niblett, chief information officer at the Michener Institute, said
the EHR On-Demand unit improves inter-professional collaboration and
provides students with a better way of learning as part of a healthcare
“Within our simulated clinical learning environments,” said Niblett, “we
can support the information needs and workflow of the healthcare team by
providing a dynamic, single point of access for patient-record
“The student healthcare team is empowered to create and launch specific
EHR platforms as required,” he added. “They can also formulate their
findings in a unique way through the power of the touch-screen
Dr. Karim Bandali, associate vice president of business development,
noted the touchscreen technology, using a 60-inch plasma monitor, allows
various clinical systems and diagnostic information to be displayed and
positioned towards a group, or more specifically, the student healthcare
Moreover, “the real value with the current iteration of this touchscreen
EHR is that the patient record becomes a fluid source of information,
delivered, assessed and developed in an inter-professional experience,
with the possibility of sharing this data live to a remote location for
secondary consideration and/or diagnosis, or for educational
experience,” said Dr. Bandali.
According to Dr. Paul Gamble, president and chief executive officer, the
Michener’s latest technological solution represents another key
milestone in an innovative curriculum that aims to move students
seamlessly from the academic to the clinical setting.
“Our curriculum is one of the first in North America to leverage
simulation-based technology in healthcare team settings to allow
students from different medical professions to interact and to
demonstrate leadership, conflict resolution and communication skills,
all in a patient-centered care environment.”
Niblett added that, “this innovation, even in its current form, has
significant implications for healthcare education and potentially the
Jason Verbovszky, manager, information management, described the
development process: “Our first set of ideas came from a demonstration
of Google Earth within the touchscreen environment.
“We immediately thought, if adding the touchscreen enablers to an
existing image-intensive application had such powerful transformative
benefits, what would happen if we applied the same technology to
diagnostic images of the human body? What would be the effect?”
The effect, he continued, was to utilize existing EHR platforms in
fundamentally different ways to support the information needs of the
healthcare team – all in a unique educational environment. “We’re hoping
this will ultimately contribute to improved patient-centred care and
The team at the Michener Institute also thanked their collaborative
partners in the innovative project. They include Relish Interactive,
Elekta, CAE Inc., and Clear Canvas.
For an online video demonstration, visit
How hospitals have transformed themselves to
achieve higher quality
Transformative Quality: The Emerging
Revolution in Health Care Performance
By Mark Hagland
Published 2009 by Productivity Press.
168 pages. (www.productivitypress.com)
Reviewed by Jerry Zeidenberg
In this new book, Mark Hagland, a veteran healthcare reporter based in
Chicago, delves into the movement to reduce medical mistakes and improve
the quality of care in U. S. hospitals. The core of the book revolves
around fascinating profiles of organizations that have found new ways to
cut back on the tragic deaths and injuries to patients that occur
through preventable medical errors.
In the process, the hospitals have virtually transformed themselves –
creating new models for the delivery of care.
Hagland emphasizes that top achievers have implemented ‘systemic’
change. Quality is not about individual improvements. Instead, it’s
about whole teams of people changing the way they do things over a
period of time.
While some changes involve sophisticated computerized technology, other
solutions are much more simple – but equally effective.
A case in point is the Brigham and Women’s Hospital, a 747-bed behemoth
in Boston. In 2001, the organization pioneered something called
WalkRounds, in which top hospital executives conduct weekly visits to
different areas of the hospital, accompanied by one or two nurses and
other professionals. The group includes at least one hospital senior
executive – either the CEO, COO, CMO, CNO or CIO. Together, they talk
about adverse events and near misses, and what may have led to those
Top managers get a shop-floor view of what’s going on at the hospital,
while front-line staff are shown that their concerns are of the utmost
What type of issues come up, asks Hagland? There’s a broad range, from a
door being open inappropriately to a nurse having trouble paging a
WalkRounds takes place each week, every week. It’s followed by “a closed
loop of analysis, discussion and further action.”
Of course, it’s critical to see hard numbers cited when trying to gauge
performance, and most of the projects profiled in the book have tracked
their work in this way. A nice example: On the pharmaceutical management
front, an 18-month test program at seven San Francisco Bay-area
hospitals improved medication administration accuracy from a baseline
rate of 83.8 percent to 93 percent. Significantly, that figure of 93
percent made use of ‘shadow observers’ to document the accuracy of the
nurses, rather than relying on self-reporting methods.
The six best-practices steps the nurses adhered to were:
• The nurse is required to compare a medication to the medical record
for the patient to whom the medication will be administered.
• The nurse must not be distracted or interrupted from the time the
medication is taken in hand until it is administered to the patient.
• The medication must be labeled from the time it is taken in hand to
the time it is delivered to the patient.
• The nurse must check two forms of identification on the patient.
• When appropriate, the nurse must explain the medication to the patient
at the time of administration.
• The nurse must document the administration of the medication to the
patient in the chart immediately after it is administered.
Medication administration errors, notes Hagland, dropped by 57 percent
during the course of the program. One might think that nurses would
baulk at the extra work required; in reality, adherence to the six best
practices increased to 92 percent by the end of the project, after
starting out at 79.5 percent.
Perhaps the most unusual of the six steps is the notion of not
interrupting the nurse as she or he administers medications. The
hospitals derived this from the ‘sterile cockpit’ concept used in the
aviation industry – when taking off, pilots are simply not interrupted,
unless it’s an emergency.
Standardization of procedures in a hospital can dramatically increase
patient safety and quality. That’s something the Pennsylvania-based
Geisinger Health System found when it instilled standard practices in
its cardiac surgery department.
The problem? Too much idiosyncrasy, as different surgeons used a variety
of techniques and treatments. That was okay for the surgeons, but it
would perplex the teams of allied professionals assisting them.
Geisinger broke down coronary artery bypass graft (CABG) operations into
41 separate steps. While national guidelines already existed for the
procedure, they were very generic – like use antibiotics appropriately.
Geisinger refined the guidelines, using evidence-based medicine from the
literature, and made the steps much more specific.
Surgeons were allowed to opt out, if they chose; opt-outs would simply
be reviewed by peers at a later date. As it turned out, only five
opt-outs occurred from the time the program started in February 2006, to
Meanwhile, in the first year of the CABG program, the patient mortality
rate dropped to 0 from 1.5 percent. Pulmonary complications fell to 2.6
percent from 7.3 percent, and the average length of stay decreased by 16
In a review of this length, we can only scratch the surface of a book
like Transformative Quality, and Hagland offers many more instructive
By way of background, Hagland traces the impetus for much of today’s
hospital quality movement to the 1999 release of the Institute of
Medicine’s report, To Err is Human, which estimated that up 98,000
Americans die each year because of preventable medical errors. That many
deaths is the equivalent of a jetliner crashing each day for a year and
killing all of its passengers.
The report was like a slap in the face to doctors and hospital
executives, along with healthcare associations and politicians. Since
then, various programs have sprung up to improve patient safety, notably
the Institute for Healthcare Improvement’s 100,000 Lives campaign.
Hagland points out that other factors have intervened since 1999. The
press is now much more aware of the issue of medical error and has been
regularly covering instances of foul-ups. It gave a great deal of news
play in 2007 to the heparin overdosing of the twin infants of actor
Dennis Quaid and his wife Kimberly Buffington. The newborns were
accidentally given 10,000 units of the anti-coagulant instead of the
required 10 units. Quick action saved the lives of the twins, but of
course, there are many others who are not so fortunate.
Complicating the whole picture is the economic background. Demand for
healthcare services has been rising and costs are exploding. Payers for
healthcare services have decided they no longer want to pay for quantity
– instead, they want quality.
Canadian regions surge ahead with interoperable
electronic health records
By Andy Shaw
Whether you call it an EMR, an EPR or an EHR, groups across Canada are
trying to electronically bridge the islands of digital records that have
sprung up in hospitals, long-term care centres, pharmacies and physician
practices. The goal? To reap the enormous cost saving and superior
patient outcomes that electronically shared health records promise.
Among them, optimists say, up to 80 percent lower chronic disease costs,
as well as dramatic reductions in redundant tests and medical errors.
None are working at this more keenly than innovators in Sudbury,
Ontario, who serve the healthcare needs of over half a million residents
in the province’s vast north-east. And they’re doing it through a shared
services agreement among 13 healthcare organizations known as NEON,
formally the North Eastern Ontario Network.
“We don’t think about ourselves very often this way, but our Dapasoft
consultants and others have convinced me that we are out there on the
leading edge,” says a modest Gaston Roy, NEON’s multi-hatted CIO.
Not to be outdone down in populous southern Ontario, Agfa HealthCare
Inc., with headquarters in Toronto, is busy helping regional hospital
groups to set world standards for health record interchange – rendering
data “silos” into easily accessible repositories.
In the West, Alberta Netcare is building on the foundation of an already
fully integrated electronic health record system – proven robust and
scalable enough to serve an entire province, which was transformed
overnight in 2008 by government decree into one giant health region.
Notable, too, for their yet again different approach are the xwave
Healthcare-led or assisted consortia in British Columbia, New Brunswick,
Nova Scotia, and Quebec. With varying scope, each consortium is making
health records “interoperable” – capable of vaulting entrenched
jurisdictional and technical barriers to information sharing.
Northern Ontario: Back in Northern Ontario, NEON and Gaston Roy’s IT
staff of 56 are anchored in Sudbury, the region’s largest city. From
there, working with the guidance of Dapasoft, a Toronto-based software
development and systems consulting firm, they have built a record
sharing system the world can envy.
“NEON really began as a Y2K exercise among eight hospitals back in
1998/99. Afterward, we went on to re-implement our Meditech clinical and
financial systems to support the whole region,” says Roy. “But then we
ran into some performance issues. And that’s where Dapasoft came in.”
With Dapasoft’s systems integration help, NEON now has a common IT
infrastructure and a standardized Meditech information system that ties
together two dozen, far-flung sites and 16 hospitals among them from its
central host at the 527-bed Sudbury Regional Hospital (where Roy is
employed as the CIO).
Live since last June, the novel data distribution network employs
BizTalk Server 2006, Microsoft’s integration engine and Dapasoft’s
Corolar interface software, to connect a plethora of applications and a
multitude of systems. As a result, BizTalk can dish Meditech and other
data to and from a regional PACS network, HIS, laboratory, WTIS (wait
time information system), and EMPI (electronic master patient index)
among others, including financial data.
Time was in Sudbury, and across Northern Ontario, if you ever used the
word “interface” in polite conversation, people thought you were talking
about some new mining technique to burrow out rock faces deep below in
the Canadian Shield.
But today, above ground, creating interfaces is a primary mission of
NEON and its caregivers.
“We have probably created over 100 interfaces and we’ve done that
through BizTalk, which acts as a broker for those interfaces. Our
programmers are very comfortable with BizTalk because they are used to
working in (Microsoft’s) .Net. BizTalk takes feeds from the admission
information at one hospital, for example, and distributes it to many
other systems. So your connections with each other are no longer
expensive point-to-point,” explains Roy. “Dapasoft helped us adapt
BizTalk to the needs of the hospital world. And they also brought their
Corolar product to bear, which expedites writing code for and thus
creating those interfaces.”
For that ingenuity, Microsoft Canada honoured Dapasoft with its top
business implementation award last year.
“I think, more than anything else, we won that award because of its
impact,” says Dapasoft president Michael Lonsway. “What Microsoft was
recognizing, particularly in light of the Canada Health Infoway
blueprint for a pan-Canadian EHR, was just how significant the work was
for successfully taking that integration and extending it beyond
Gaston Roy has even more extensions in the works. “We’re just finalizing
adding six more institutions to NEON this year and we’re continuing to
develop more interfaces.”
Among them will be an interface for a higher level of wait-time
programming, developed in co-operation with Dapasoft, which will improve
the quality of data flowing into the Ontario wait-time system.
Regional healthcare providers are also confident they’ve got the tools
to continue integrating various types of data, from different sources.
“We are now comfortable with sharing our information with other partners
like the national HIAL (health information access layer) initiative in
HL7 or XML or other standards,” says Roy. “But I think it is not so much
the technology as it is our knowledge that will make us survive and
Southern Ontario: Agfa HealthCare sees itself growing by building what
it views as the cornerstone of any electronic record system – readily
accessible patient data repositories. Today, nine of 16 such
repositories in Canada use Agfa’s technology.
Accessed through Agfa’s web-based Impax Clinical Dashboard viewer, the
data centres allow different hospitals to view, enter, and share patient
records. By signing on with Agfa recently as a shared services group,
The Credit Valley, William Osler Health Centre, and Halton Healthcare
Services hospitals in the Toronto area, and all six of their sites, in
effect knocked down the information silos that kept them apart.
“If patients are getting examinations, tests, and other things done at
different facilities as patients do these days, the challenge is to get
all those records into one single view,” says Dave Wilson, Agfa’s
vice-president for healthcare. “And if one record or part of that view
is missing, then the physician can’t make a fully informed decision. But
now, from every one of those three hospitals and their sites, a
clinician can log in and see all of a patient’s records.”
Interestingly, the pundits often point out that European countries are
way ahead of Canada when it comes to the electronic health record. But
what’s remarkable about regions in Canada – such as Northern Ontario and
also at Credit Valley, William Osler and Halton Healthcare – is that the
electronic health records are interoperable. That’s quite rare, in North
America, Europe and around the world.
“In those countries [like Denmark, Norway and Sweden], there’s a
personal electronic health record now for every one of their citizens,”
says Wilson. “While that’s admirable, those records by-and-large are
still not shared much. So if your house straddles a boundary between two
health regions in Sweden, for example, and if you injure yourself by
falling out the back door instead of the front door, you might have to
have a whole new hospital record made up for you.”
Similarly in the United Kingdom, adds Wilson. Even though the National
Health Service (NHS) there is seeing to it that everyone in England will
soon have an electronic record, the NHS hasn’t made much progress on
having those records easily shared among regions.
“But here in Canada, we have,” says Wilson. “We are taking the so-called
longitudinal view of the EHR. That means no matter where patients go,
their past results can be compared to their current conditions.”
Agfa’s edge in enabling the longitudinal view of patient records stems
from its nimble Enterprise Clinical Dashboard. As Wilson puts it,
Dashboard users can “peer into the patient data repositories” at any
time and pull out sought after data in real-time – regardless of what
system produced them.
“In other words, hospitals that want to share data don’t need to be all
on one Meditech or any other single information system,” says Wilson.
Naturally, being able to interface old legacy systems with new patient
data repositories has a number of big advantages, including big savings.
“You don’t need any expensive ‘rip & tear’ of your current system. Also,
training and learning curves are minimal, because you only need to learn
one new system (Dashboard) which can access them all,” says Wilson.
Usage of the Dashboard makes healthcare delivery more accurate for
physicians and nurses – because it gives them access to the patient’s
records, no matter which hospital the patient last visited. That, of
course, results in faster and higher-quality care.
It’s also more convenient for patients.
If we make health records shareable by virtue of making and storing them
electronically, “then my Mother is going to be less insistent she always
go to the Oshawa hospital rather than a more convenient one because, as
she says, ‘Oshawa is where all my (paper) records are!’”
The work being done in Canada on interoperability of electronic records
is no small achievement.
“We are very conscious that what we are developing here in Canada can be
applied in the rest of the world, especially where there are public
healthcare systems like ours,” says Wilson.
Systems refined in Canada may also appeal to the largely private
healthcare system of the U.S., where local information sharing
initiatives have started in the form of Regional Health Information
Organizations (RHIOs). These efforts, which have stumbled in the last
few years, will now be fuelled by President Barack Obama’s recent
stimulus bill, in which US$2 billion was given to a federal organization
charged with building networks and the standards they require.
It is this international potential for Canadian-developed health record
and information sharing that has prompted the company to put up $170
million for Agfa HealthCare funded research and development centres in
Waterloo and Toronto. The sum was topped up with another $29.6 million
from the Province of Ontario – knowing there’s a market for electronic
record keeping and other workflow improving systems in healthcare that’s
If there are challenges ahead for the rest of the world, including
Canada, in this drive to share records, they are likely to be not so
much technical as human, thinks Wilson.
“Acceptance of any new system by people who use it, of course, is always
a problem. And that is especially true of caregivers in healthcare. But
it has been our experience in implementing change that those who
complain about it most, at first, are often the ones to complain loudest
if you try to take it away from them,” says Wilson. “If it is a good
system, it becomes like my BlackBerry has become to me. You can’t live
That’s not to say that in all this record sharing there are not still
technical gaps to close.
Says Wilson: “If we are truly going to have a longitudinal view of all
our patients, then we’re going to have to include cardiac imaging and
PACS records, which are not yet being shared nearly as much as they
Ironically, as Wilson points out, the digital revolution that has
overtaken much of diagnostic imaging, can itself be a barrier to record
“Hospitals that have digitized and gone filmless often can’t share a
record with another digitized hospital at all – because their computer
systems can’t talk to each other.” What’s more, says Wilson, these
filmless hospitals can no longer send each other a piece of film –
something they could do in the past, even if it took days or weeks.
Which means interoperability is urgently needed for the new, electronic
Alberta: In the not so distant past, Alberta was made up of nine
healthcare regions. No longer. In one fell swoop last spring, the
Alberta government collapsed them into one. In the process, it took much
of the complexity out of sharing Alberta health records, says Mark
Bresson, an assistant deputy minister with the Alberta Health and
Bresson heads the ministry’s Information Strategic Services division and
is therefore responsible for Netcare, Alberta’s initiative to build a
single, province-wide EHR. In that position he sees strategic advantages
stemming from last year’s dramatic consolidation.
“It has wiped out the duplication of effort and reduced the number of
data repositories we’re going to need as Netcare evolves,” says Bresson,
who holds a graduate degree in health information science.”
The data repositories currently in place are providing the province’s
physicians with up-to-date, but essentially basic medical history data
that’s helpful at the point of care.
“It’s been all about labs, drugs, DI, and text reports,” says Bresson.
“But Netcare is not a project. It is a constantly evolving program. So
now we are beginning to look at the ‘shared’ components of the health
record that Canada Health Infoway would like to see in place and which
go beyond the basic source systems we have working for us now.”
Bresson says his division is liaising with physicians and other
providers to determine what other data sets exist in the office EMR that
other clinicians treating the patient in other settings would like to
“It could be immunizations, or adverse reactions, or perhaps problem
notes,” says Bresson. “But it would not be everything that a doctor’s
Alberta Netcare is also evolving, reports Bresson, to much more sharing
of records with patients. It now has a personal health portal under
“Right now our Netcare portal is a provider portal. If patients want to
see their records, they have to be with the provider,” explains Bresson.
“But our surveys tell us patients want to have better access to their
health information and they want to manage that information.”
Bresson says the patient portal is still in the early stages, but
expects that by the end of the 2009/2010 fiscal year decisions will have
been made on the kind of data, the technology, and the security and
privacy issues inherent in patient access.
Another project Alberta Health and Wellness has under way will
facilitate that access to Netcare and its patient data repositories –
moving further away from the nine-region complexity Alberta healthcare
was and towards one-region simplicity.
“We’re pursuing a single sign-on for Netcare. So we are moving quickly
with identity and access management software to that end,” says Bresson.
“The single sign-on will allow us to move away from having so many
security ID’s and passwords. That’s what we’re hearing from our users.
They appreciated what has been built, so far, but the system is still
too complicated to access.
Quebec, New Brunswick, Nova Scotia, British Columbia: It’s a firm belief
on the part of those at xwave Healthcare that easy and widespread access
to an electronic health record system is a question of what ‘level’ it
“We like the term ‘interoperable’ to describe what an electronic health
record is. And to be interoperable, the EHR needs to sit outside of and
above hospital or doctor office walls at what we call the
‘jurisdictional’ level,” says Nadeem Ahmed, the managing director and VP
And xwave Healthcare, a division of Bell Aliant, is walking that talk as
the project leader for provincial-wide implementations of an “I-EHR” for
the entire provinces of Quebec and New Brunswick. xwave is also playing
a supporting role in the implementation of similar I-EHRs in Nova Scotia
and British Columbia.
But down at the clinical level, where doctors deal directly with
patients, what difference does it make to have an I-EHR positioned much
“In the simplest of terms, today clinical decisions are being made with
incomplete information,” replies Ahmed. “Today, physicians are treating
patients with only the data they have in their own records or the data
they are supplied with by an imperfect memory and understanding of the
patient. So the purpose of the I-EHR, and these provincial projects, is
to supply clinicians with all of the data that is available, so that the
clinician can make a more effective diagnosis and treatment plan.”
But that’s not ultimately where these I-EHR implementations will lead,
says xwave’s managing director and head of business development, Gary
“The least expensive members of the healthcare system are patients and
their families. So if you can get data and information into their hands
through the I-EHR, which helps them become their own caregivers, you can
save the healthcare system enormous amounts of money,” says Folker.
“It’s been estimated, for instance, that health records shared this way
could reduce our chronic care expenses by 80 percent, and they account
for 80 percent of our costs.”
Folker adds that xwave’s experience with electronic record sharing
systems in four provinces points towards a more rational healthcare
system. Electronic records in all their forms can help re-shape
healthcare policy and capital investment, he thinks, because they supply
better data of how many persons are sick where, with what – data that
can be made available to decision makers.
“You can then ask questions like: Where are the greatest incidences of
heart failure or lung cancer, and then decide where your cardiac
hospitals or cancer clinics go.” That’s ultimately good for patients,
and for the sustainability of Canada’s healthcare system.